Hospital/Facility Provider Application

Transcription

1 Hospital/Facility Provider Application Instructions: In order for the application to be considered complete: 1. All information must be legible. Please print or type all information. 2. A separate application must be completed for each Legal Entity/TIN. 3. The Application must be signed and dated. 4. If necessary, use a separate sheet of paper to provide additional information. 5. The original application with attachments should be attached to the Provider Agreement. 6. Fill-in the Tax ID# at the bottom of every page for reference purposes. Attach the following to the completed application: State Operational License Other applicable State/Federal Licensures (e.g., CLIA, DEA, Pharmacy or Department of Health) Accreditation/Certification (by a nationally recognized accrediting body, e.g., TJC/JCAHO) If not accredited by a nationally recognized accrediting body, attach the Site Evaluation Results from a governmental agency W-9 Ownership and Disclosure Form For Medicare/Medicaid Plans (MMP), attach the MMP Directory Requirements form Other applicable State/Federal Licensures (See last page for list of state-required documents) Initial Credentialing/ Re-Credentialing/ Addition of new site to current contract Assessment Re-Assessment Legal Entity/TIN: This application applies to the following Provider Types: (Choose all that apply) Adult Day Care Center; Clinic Indian Health Center (IHC); Hospice; Adult Living Facility/Assisted Living Facility; Agency (Dept. of Health, State Health); Ambulance; Assisted Long-Term Care Facility; Board of Health; Clinic Federally Qualified Health Center (FQHC); Clinic Rural Health Clinic (RHC); Diagnostic Imaging Center; Dialysis; Durable Medical Equipment; Home & Community Based Services (HCBS); Home Health Agency; Hospital; Skilled Nursing Facility; Skilled Nursing Facility; Surgical Center; Urgent Care (Attached to Hospital); Urgent Care (Free Standing); 6/18/15 Version 7 Page 1

2 Contact Information: If questions about this application, contact: Fax Number: Credentialing Contact Information: If questions about this application, contact: Same as Contact Information Fax Number: Legal Entity Information (Name on Income Tax Return) Tax ID Holder Name: Federal Tax ID Number: Legal/Tax Address (where you want the 1099 sent): Insurance Information Carrier: Amount of Coverage: Dates: Billing Information Pay To Name (Issue check to): Note: May be different than name on the Pay To Address (Send remittance to: City, State, Zip: Billing Contact Name: Billing Contact Fax Number: HCBS/Home Health Agencies Servicing Counties: Servicing County 1: Servicing County 2: Servicing County 3: Servicing County 4: Note: Each Provider Type/NPI listed on in the Provider Type Grid on Page 1, must have one service location. 6/18/15 Version 7 Page 2

3 Complete for each Service Location that is part of this application.. Service Location 1 of Group or Facility Name (to be displayed in the Directory) Tax ID Number: Provider Type: National Provider ID # (NPI): State License Number: Medicaid Number: Medicare Number: Service Location Address: Physical Street Address: City, State, Zip: County Main Switchboard Service Location Fax Number Service Location Office Hours: Office Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours 24 Hours 8 5 Service Location Handicap Service Location Accepting New ADA Compliant? Yes No Access? Yes No Patients? Yes No Please list any Foreign Languages spoken at this location: Is your practice limited to certain ages? Yes No If Yes, specify age restrictions: None 0-2 years 0-12 years 0-17 years 0-20 years 13+ years Other years years 3+ years 17+ years 21+ years 65+ years Billing Information for Service Location 1 of : Same as indicated on Page 2 (If different, complete below) Pay To Name (Issue check to): Note: May be different than name on the Pay To Address (Send remittance City, State, Zip: to: Billing Contact Name: Billing Contact Fax Number: Insurance Information for Service Location 1 of : Same as indicated on Page 2 (If different, complete below ) Carrier: Amount of Coverage: Dates: 6/18/15 Version 7 Page 3

4 Service Location 1 of - Accreditation/Certification Type Please provide a copy of these documents; including the Survey Results and a report that shows the effective date of accreditation or certification, deficiencies and approved corrective action plan. Agency Name Level Status Applied Date Expiration Date Accreditation Commission for Health Care (AHCH) American Association of Ambulatory Health Centers (AAAHC) American Board for Certification in Orthotics & Prosthetics, Inc. (ABCOP) American College of Radiology (ACR) American Osteopathic Hospital Association (AOHA) Board of Orthotist / Prosthetist Certification (BOCUSA) Clinical Laboratory Improvement Act (CLIA) Commission on Accreditation for Rehab Facilities (CARF) Community Health Accreditation Program (CHAP) Healthcare Quality Association on Accreditation (HQAA) The Joint Commission (TJC (aka JCAHO)) Det Norske Veritas/National Integrated Accreditation for Healthcare Organizations (DNV/NIAHO) National Association of Boards of Pharmacy (NABP National Committee for Quality Assurance (NCQA) State Facility Operating License The National Board of Accreditation for Orthotic Suppliers (NBAOS) Utilization Review Accreditation Commission/Accreditation HealthCare Commission, Inc. (URAC) Others (please list): Service Location 1 of Sanctions If yes, to any question below, please explain on a separate sheet of paper. Have there been any settled malpractice claims, suites, settlements or proceedings involving your Organization within the past five years? Has your Organization ever been disciplined, fined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state government health care plans or programs? Has an officer of your Organization ever been convicted of, pled guilty to, or pled no lo contendere to any felony including an act of violence, child abuse, or a sexual offense? Tax ID Number: Complete for each Service Location that is part of this application. (Make additional copies as needed) 6/18/15 Version 7 Page 4 Yes Yes Yes No No No

5 Additional Service Locations Service Location of Group or Facility Name (to be displayed in the Directory) Tax ID Number: Provider Type: National Provider ID # (NPI): State License Number: Medicaid Number: Medicare Number: Service Location Address: Physical Street Address: City, State, Zip: County Main Switchboard Service Location Fax Number Service Location Office Hours: Office Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours 24 Hours 8 5 Service Location Handicap Service Location Accepting New ADA Compliant? Yes No Access? Yes No Patients? Yes No Please list any Foreign Languages spoken at this location: Is your practice limited to certain ages? Yes No If Yes, specify age restrictions: None 0-2 years 0-12 years 0-17 years 0-20 years 13+ years Other years years 3+ years 17+ years 21+ years 65+ years Billing Information for Service Location of : Same as indicated on Page 2 (If different, complete below) Pay To Name (Issue check to): Note: May be different than name on the Pay To Address (Send remittance City, State, Zip: to: Billing Contact Name: Billing Contact Fax Number: Insurance Information for Service Location of : Same as indicated on Page 2 (If different, complete below) Carrier: Amount of Coverage: Dates: Additional Service Locations (continued) (Make additional copies as needed) 6/18/15 Version 7 Page 5

6 Service Location of - Accreditation/Certification Type Please provide a copy of these documents; including the Survey Results and a report that shows the effective date of accreditation or certification, deficiencies and approved corrective action plan. Agency Name Level Status Applied Date Expiration Date Accreditation Commission for Health Care (AHCH) American Association of Ambulatory Health Centers (AAAHC) American Board for Certification in Orthotics & Prosthetics, Inc. (ABCOP) American College of Radiology (ACR) American Osteopathic Hospital Association (AOHA) Board of Orthotist / Prosthetist Certification (BOCUSA) Clinical Laboratory Improvement Act (CLIA) Commission on Accreditation for Rehab Facilities (CARF) Community Health Accreditation Program (CHAP) Healthcare Quality Association on Accreditation (HQAA) The Joint Commission (TJC (aka JCAHO)) Det Norske Veritas/National Integrated Accreditation for Healthcare Organizations (DNV/NIAHO) National Association of Boards of Pharmacy (NABP National Committee for Quality Assurance (NCQA) State Facility Operating License The National Board of Accreditation for Orthotic Suppliers (NBAOS) Utilization Review Accreditation Commission/Accreditation HealthCare Commission, Inc. (URAC) Others (please list): Service Location of Sanctions If yes, to any question below, please explain on a separate sheet of paper. Have there been any settled malpractice claims, suites, settlements or proceedings involving your Organization within the past five years? Has your Organization ever been disciplined, fined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state government health care plans or programs? Has an officer of your Organization ever been convicted of, pled guilty to, or pled no lo contendere to any felony including an act of violence, child abuse, or a sexual offense? Yes No Yes No Yes No PROVIDER RESPONSIBILITY STATEMENT 6/18/15 Version 7 Page 6

7 I hereby understand that as a prospective/current Louisiana Healthcare Connections provider, I am solely responsible for ensuring that any licensed practitioners under my employment or working in association with my clinical practice are fully qualified and have all necessary licenses required by all relevant laws to legally perform the assigned functions within my practice. Further, I agree that each such individual must be fully presented to Louisiana Healthcare Connections Credentials Committee for their review and approval, and, absent such affirmative approval, Louisiana Healthcare Connections members assigned to my care may not be treated or assisted by such individuals under my employment or associated to my practice without prior approval from Louisiana Healthcare Connections. Further, from time to time, such licensed practitioners may change, as my practice associates. In all such cases, I accept responsibility for notifying Louisiana Healthcare Connections in a timely manner about these new arrangements and will be responsible for fully cooperating in the submission of completed application forms and providing any other information as may be required to satisfy Louisiana Healthcare Connections credentials/re-credentials requirements for all such individuals associated with my practice. By applying for participation to the Plan, I hereby fully understand that the information submitted in this application shall be held confidential by the Plan and provided only to individuals connected with the Plan on a need to know basis. Notwithstanding the foregoing, I agree to the following: Participation in the credentialing review functions of the Plan. Authorize the Plan and its representatives to consult with prior or current associates and others who may have information bearing on our professional competence, character, health status, ethical qualifications, ability to work cooperatively with others and other qualifications needed for verification of credentials. This includes such primary source verifications as accreditation bodies, professional liability carriers, State and Federal agencies or any other verification entities required by the Plan s accrediting bodies, CMS, DOM, or other State or Federal regulatory agencies. Consent to an inspection by the Plan and its representatives of all documents that may be material to an evaluation of qualifications and competence. This is applicable if the applicant is not accredited by a nationally recognized accrediting body. Consent to the release of such information for credentialing purposes. Release from liability all representatives of the Plan for their acts performed and statements made, in good faith and without malice, in connection with evaluating the application, credentials and qualification for determination of credentialing status. Acknowledge that I, the Applicant, have the burden of producing adequate information for a proper evaluation of our professional, ethical and other qualifications for credentialing purpose and for resolving any doubts about such qualifications. Acknowledge that any material misstatement in, or omissions from, this application constitute cause for denial of credentialing status or cause for summary for revocation or suspension of privileges and/or dismissal from the participating network. STATEMENT OF APPLICATION/AUTHORIZATION FOR RELEASE OF INFORMATION In order to evaluate this application for participation in and/or continued participation in the Plan, the Facility hereby gives permission to the Plan to request from other entities information regarding the Facility s credentials and qualifications. This includes consent to contact the Facility s accreditation agencies, State Regulatory and Licensing Departments, professional liability and workers compensation insurance carriers. The Facility understands that the Plan will use this information in a confidential manner on its own behalf and, if applicable, as an agent for one of its affiliated networks in connection with the administration of the Plan. The Facility certifies that the information provided and the answers to the questions on this application are accurate and complete. While this application is being evaluated, and if this Facility/Subcontractor is selected or retained, after such selection or retention, the Facility agrees to inform the Plan in writing within 15 days of any changes in the information provided and the answers to questions on the application as a result of developments subsequent to the execution of this application. The Facility agrees that submission of this application does not constitute selection or retention by the Plan on its own behalf or, if applicable, as an agent for one of its affiliated Plans and if the Facility is initially applying for participation, grants this Facility no rights or privileges in any Plan programs or any program or one of its affiliated Plans until such time as this Facility receives notice of selection. All information submitted in this application is true and complete to the best of my/our knowledge and belief. A photo copy of this original constitutes our written authorization and requests to release any and all documentation relevant to this application. Said photo copy shall have the same force and effect as the signed original. Name of Provider: Date: Print or type name Signature of Provider or Authorizing Representative Title A stamp signature is not acceptable 6/18/15 Version 7 Page 7